Guidelines for management of HIV infection with computer-based patient's record

doi:10.1016/S0140-6736(95)92226-1

The Lancet

Volume 346, Issue 8971, 5 August 1995, Pages 341-346

https://doi.org/10.1016/S0140-6736(95)92226-1 Get rights and content

Abstract

Summary

Computers are steadily being incorporated in clinical practice. We conducted a nonrandomised, controlled, prospective trial of electronic messages designed to enhance adherence to clinical practice guidelines. We studied 126 physicians and nurse practitioners who used electronic medical records when caring for 349 patients with HIV infection in a primary care practice. We analysed the response times of clinicians to the situations that triggered alerts and reminders, the number of ambulatory visits, and hospitalisation.

The median response times to 303 alerts in the intervention group and 388 alerts in the control group were 11 and 52 days (p<0·0001), respectively. The median response time to 432 reminders in the intervention group was 114 days and that for 360 reminders in the control group was over 500 days (p<0·0001). There was no effect on visits to the primary care practice. There was, however, a significant increase in the rate of visits outside the primary care practice (p=0·02), which is explained by the increased frequency of visits to ophthalmologists. There were no differences in admission rates (p=0·47), in admissions for pneumocystosis (p=0·09), in visits to the emergency ward (p=0·24), or in survival (p=0·19). We conclude that the electronic medical record was effective in helping clinicians adhere to practice guidelines.

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Cited by (116)

Implementation of an electronic medical record does not change delivery of preventive care for HIV-positive patients
2014, International Journal of Medical Informatics
Citation Excerpt :
Our findings are consistent with many studies of EMR effects on health care quality. While there are some studies which have found improvements with specific health outcomes measures [14–21], others have found that only some of the health measures studied showed improvement with EMRs [22–27]. Other studies, including the study with the largest sample size to date showed that there was no improvement in outcomes when an EMR was used [28–31].
This study sought to determine the impact that an electronic medical record (EMR) had on the provision of preventive health measures – including obtaining serologies for viral hepatitis and administering vaccinations to non-immune patients – to HIV patients at a hospital-based clinic.
Using a pre–post study design, we compared rates of preventive health delivery to HIV patients at an outpatient clinic during the use of a paper medical record (PMR) and after implementation of an EMR. Retrospective chart reviews were conducted at two time points: 12–16 months prior to and 24 months following EMR implementation. The records of 160 active patients were randomly selected for review during both time periods.
There was no difference between the PMR and EMR samples with regard to the proportion of patients who had hepatitis A (83% in PMR group; 77% in EMR) and hepatitis C (94% in both groups) serologies measured or the proportion of eligible patients who were given hepatitis vaccinations. Slightly fewer patients had a serology for hepatitis B measured in the EMR sample.
As EMR implementation expands, it is important to evaluate the effects that EMRs have on patient outcomes, including preventive health provision. Our study showed that after implementation of an EMR, the provision of most preventive care measures did not improve. This finding is in agreement with many published studies. Some studies have found positive effects from EMRs that may be attributable to specific aspects of EMRs. Further study of the effect of specific EMR attributes on health care outcomes is needed.
The effect of electronic medical record-based clinical decision support on HIV care in resource-constrained settings: A systematic review
2012, International Journal of Medical Informatics
Citation Excerpt :
This has been demonstrated through better diagnosis, reduced medication errors [5,7] and improved practitioner performance [8]. Studies conducted in the US and other developed countries have shown that CDSS can improve quality of HIV care through improved compliance with guidelines [9,10]. On the other hand, a systematic review by Tawadrous et al. showed that many studies were often limited by the evaluation method used and benefits can only be reported selectively [11].
It is estimated that one million people infected with HIV initiate anti-retroviral therapy (ART) in resource-constrained countries annually. This occurs against a background of overburdened health workers with limited skills to handle rapidly changing treatment standards and guidelines hence compromising quality of care. Electronic medical record (EMR)-based clinical decision support systems (CDSS) are considered a solution to improve quality of care. Little evidence, however, exists on the effectiveness of EMR-based CDSS on quality of HIV care and treatment in resource-constrained settings.
The aim of this systematic review was to identify original studies on EMR-based CDSS describing process and outcome measures as well as reported barriers to their implementation in resource-constrained settings. We characterized the studies by guideline adherence, data and process, and barriers to CDSS implementation.
Two reviewers independently assessed original articles from a search of the MEDLINE, EMBASE, CINAHL and Global Health Library databases until January 2012. The included articles were those that evaluated or described the implementation of EMR-based CDSS that were used in HIV care in low-income countries.
A total of 12 studies met the inclusion criteria, 10 of which were conducted in sub-Saharan Africa and 2 in the Caribbean. None of the papers described a strong (randomized controlled) evaluation design. Guideline adherence: One study showed that ordering rates for CD4 tests were significantly higher when reminders were used. Data and process: Studies reported reduction in data errors, reduction in missed appointments, reduction in missed CD4 results and reduction in patient waiting time. Two studies showed a significant increase in time spent by clinicians on direct patient care. Barriers to CDSS implementation: Technical infrastructure problems such as unreliable electric power and erratic Internet connectivity, clinicians’ limited computer skills and failure by providers to comply with the reminders are key impediments to the implementation and effective use of CDSS.
The limited number of evaluation studies, the basic and heterogeneous study designs, and varied outcome measures make it difficult to meaningfully conclude on the effectiveness of CDSS on quality of HIV care and treatment in resource-limited settings. High quality evaluation studies are needed. Factors specific to implementation of EMR-based CDSS in resource-limited setting should be addressed before such countries can demonstrate its full benefits. More work needs to be done to overcome the barriers to EMR and CDSS implementation in developing countries such as technical infrastructure and care providers’ computer illiteracy. However, simultaneously evaluating and describing CDSS implementation strategies that work can further guide wise investments in their wider rollout.
Electronic decision protocols for ART patient triaging to expand access to HIV treatment in South Africa: A cross sectional study for development and validation
2012, International Journal of Medical Informatics
The shortage of doctors and nurses, along with future expansion into rural clinics, will require that the majority of clinic visits by HIV infected patients on antiretroviral therapy (ART) are managed by non-doctors. The goal of this study was to develop and evaluate a screening protocol to determine which patients needed a full clinical assessment and which patients were stable enough to receive their medications without a doctor's consultation. For this study, we developed an electronic, handheld tool to guide non-physician counselors through screening questions.
Patients visiting two ART clinics in South Africa for routine follow-up visits between March 2007 and April 2008 were included in our study. Each patient was screened by non-physician counselors using the handheld device and then received a full clinical assessment. Clinicians’ report on whether full clinical assessment had been necessary was used as the gold standard for determining “required referral”. Observations were randomly divided into two datasets – 989 for developing a referral protocol and 200 for validating protocol performance.
A third of patients had at least one physical complaint, and 16% had five or more physical complaints. 38% of patients required referral for full clinical assessment. We identify a subset of questions which are 87% sensitive and 47% specific for recommended patient referral.
The final screening protocol is highly sensitive and could reduce burden on ART clinicians by 30%. The uptake and acceptance of the handheld tool to support implementation of the protocol was high. Further examination of the data reveals several important questions to include in future referral algorithms to improve sensitivity and specificity. Based on these results, we identify a refined algorithm to explore in future evaluations.
Applying A/B testing to clinical decision support: Rapid randomized controlled trials
2021, Journal of Medical Internet Research
Medicine in a forgotten corner of Africa: How EMR can benefit the developing world – the FIMRC and EMR4DW experience
2021, European Review for Medical and Pharmacological Sciences
The influence of electronic reminders on recording diagnoses in a primary health care emergency department: a register-based study in a Finnish town
2021, Scandinavian Journal of Primary Health Care

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Guidelines for management of HIV infection with computer-based patient's record

Abstract

Comput Biomed Res

Lancet

Am J Prev Med

Clinical Practice Guideline: evaluation and management of early HIV infection

Paying the medical cost of the HIV epidemic: a review of policy options

J Acquir Immun Defic Syndr

Caring for people with AIDS and HIV infection in hospital-based primary care practice

J Gen Intern Med

Human immunodeficiency virus (HIV) infection

Ann Intern Med

Clinical computing in a teaching hospital

N Engl J Med

Role of computing in patient care in two hospitals

MD Comput

Departmental and laboratory computing in two hospitals

MD Comput

A computer-based outpatient medical record for a teaching hospital

MD Comput

The development of knowledge-based medical records for clinicians caring for patients with HIV infection

An electronic medical record that helps care for patients with HIV infection

Proc Annu Symp Comput Appl Med Care

Asymptotically efficient rank invariant test procedures

J R Stat Soc A

Generalized Linear Models

Protection of confidentiality in the computer-based patient record

MD Comput

Designing studies of computer-based alerts and reminders

MD Comput